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Griveas I. Therapeutic Apheresis and Nephrologist: New and old aspects. Transfus Apher Sci 2024; 63:103849. [PMID: 38008687 DOI: 10.1016/j.transci.2023.103849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
The clinical efficacy of therapeutic apheresis is still controversial. We undertook a retrospective review of apheresis treatment to ascertain its safety and efficacy. The therapeutic apheresis consists of a continuously improving therapeutic method for diseases with high mortality and morbidity, especially in cases with poor outcome by using current medications.
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Affiliation(s)
- Ioannis Griveas
- Army Share Fund Hospital of Athens, 417 NIMTS, Konitsis 3-5, Maroussi, 15125 Maroussi, Athens, Greece.
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2
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Azzam M, Awad A, Abugharbyeh A, Kahaleh B. Myocarditis in connective tissue diseases: an often-overlooked clinical manifestation. Rheumatol Int 2023; 43:1983-1992. [PMID: 37587233 DOI: 10.1007/s00296-023-05428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
To discuss what is currently known about myocarditis in the context of major connective tissue diseases, including Systemic lupus erythematosus, Rheumatoid Arthritis, Sjogren, Dermato-myositis and Polymyositis, Systemic Sclerosis, and Mixed connective tissue disease. Variability exists between studies regarding the incidence of myocarditis in connective tissue diseases, which is hypothesized to be the result of its subclinical course in most cases. Extensive gaps of knowledge exist in the field of pathophysiology. Although endomyocardial biopsy remains to be the gold standard for diagnosis, the advancement in non-invasive modalities such as cardiac MRI, echocardiography, and nuclear medicine has allowed for earlier and more frequent detection of myocarditis. A lack of treatment guidelines was found across the different connective tissue diseases. Most of the literature available revolved around myocarditis in the context of Systemic lupus erythematosus. Numerous recent studies were published that contributed to advancements in diagnosis and treatment however, there remains a lack of diagnostic and treatment guidelines.
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Affiliation(s)
- Muayad Azzam
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan.
| | - Amro Awad
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Aya Abugharbyeh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
| | - Bashar Kahaleh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
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3
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Gulhane A, Ordovas K. Cardiac magnetic resonance assessment of cardiac involvement in autoimmune diseases. Front Cardiovasc Med 2023; 10:1215907. [PMID: 37808881 PMCID: PMC10556673 DOI: 10.3389/fcvm.2023.1215907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Cardiac magnetic resonance (CMR) is emerging as the modality of choice to assess early cardiovascular involvement in patients with autoimmune rheumatic diseases (ARDs) that often has a silent presentation and may lead to changes in management. Besides being reproducible and accurate for functional and volumetric assessment, the strength of CMR is its unique ability to perform myocardial tissue characterization that allows the identification of inflammation, edema, and fibrosis. Several CMR biomarkers may provide prognostic information on the severity and progression of cardiovascular involvement in patients with ARDs. In addition, CMR may add value in assessing treatment response and identification of cardiotoxicity related to therapy with immunomodulators that are commonly used to treat these conditions. In this review, we aim to discuss the following objectives: •Illustrate imaging findings of multi-parametric CMR approach in the diagnosis of cardiovascular involvement in various ARDs;•Review the CMR signatures for risk stratification, prognostication, and guiding treatment strategies in ARDs;•Describe the utility of routine and advanced CMR sequences in identifying cardiotoxicity related to immunomodulators and disease-modifying agents in ARDs;•Discuss the limitations of CMR, recent advances, current research gaps, and potential future developments in the field.
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Affiliation(s)
- Avanti Gulhane
- Department of Radiology, University of Washington, School of Medicine, Seattle, WA, United States
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4
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Luo S, Dou WQ, Schoepf UJ, Varga-Szemes A, Pridgen WT, Zhang LJ. Cardiovascular magnetic resonance imaging in myocardial involvement of systemic lupus erythematosus. Trends Cardiovasc Med 2023; 33:346-354. [PMID: 35150849 DOI: 10.1016/j.tcm.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/18/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that primarily affects young women. Myocardial involvement in SLE frequently occurs and it is rather challenging to make the diagnosis in current clinical settings, mainly due to the extensive clinical presentation of signs and symptoms. As a noninvasive imaging reference in diagnosing cardiomyopathy and myocarditis, cardiovascular magnetic resonance (CMR) imaging can provide new insight into myocardial abnormalities including inflammation, fibrosis, and microcirculation. Therefore, the main aim of this work was to systematically review the pathology, clinical features, and diagnosis, while illustrating the clinical role of CMR on myocardial involvement of SLE.
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Affiliation(s)
- Song Luo
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | | | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Wanya T Pridgen
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA
| | - Long Jiang Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China.
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5
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Böhme R, Daniel C, Ferrazzi F, Angeloni M, Ekici AB, Winkler TH, Hilgers KF, Wellmann U, Voll RE, Amann K. Cardiovascular changes in the NZB/W F1 mouse model of lupus nephritis. Front Cardiovasc Med 2023; 10:1182193. [PMID: 37554366 PMCID: PMC10405627 DOI: 10.3389/fcvm.2023.1182193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/04/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Patients with systemic lupus erythematosus (SLE), an autoimmune disease, have a higher risk of cardiovascular (CV) disease and death. In addition, up to 40%-50% of SLE patients develop lupus nephritis (LN) and chronic kidney disease, which is an additional CV risk factor. Thus, the individual contributions of LN and other SLE-specific factors to CV events are unclear. METHODS In this study, we investigated the effect of LN on the development of CV changes using the female NZBxNZW F1 (NZB/W) mouse model of lupus-like disease, with female NZW mice as controls. Standard serologic, morphologic, immunohistologic, and molecular analyses were performed. In a separate group of NZB/W mice, systolic blood pressure (BP) was measured during the course of the disease using tail plethysmography. RESULTS Our data show marked CV changes in NZB/W mice, i.e., increased heart weight, hypertrophy of the left ventricle (LV) and septum, and increased wall thickness of the intramyocardial arteries and the aorta, which correlated with the progression of renal damage, but not with the age of the mice. In addition, systolic BP was increased in NZB/W mice only when kidney damage progressed and proteinuria was present. Pathway analysis based on gene expression data revealed a significant upregulation of the response to interferon beta in NZB/W mice with moderate kidney injury compared with NZB mice. Furthermore, IFI202b and IL-6 mRNA expression is correlated with CV changes. Multiple linear regression analysis demonstrated serum urea as a surrogate marker of kidney function and IFI202b expression as an independent predictor for LV wall thickness. In addition, deposition of complement factors CFD and C3c in hearts from NZB/W mice was seen, which correlated with the severity of kidney disease. CONCLUSIONS Thus, we postulate that the pathogenesis of CV disease in SLE is affected by renal impairment, i.e., LN, but it can also be partly influenced by lupus-specific cardiac expression of pro-inflammatory factors and complement deposition.
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Affiliation(s)
- Romy Böhme
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Christoph Daniel
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Fulvia Ferrazzi
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
- Institute of Pathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Miriam Angeloni
- Institute of Pathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Arif Bülent Ekici
- Institute of Human Genetics, University Hospital Erlangen, Friedrich–Alexander–Universität Erlangen–Nürnberg, Erlangen, Germany
| | - Thomas H. Winkler
- Divison of Genetics, Department of Biology, Nikolaus–Fiebiger–Center of Molecular Medicine, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Karl-Friedrich Hilgers
- Department of Nephrology and Hypertension, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Ute Wellmann
- Divison of Genetics, Department of Biology, Nikolaus–Fiebiger–Center of Molecular Medicine, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
| | - Reinhard E. Voll
- Department of Rheumatology and Clinical Immunology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kerstin Amann
- Department of Nephropathology, Friedrich–Alexander–Universität (FAU) Erlangen–Nürnberg, Erlangen, Germany
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6
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Nor MA, Ogedegbe OJ, Barbarawi A, Ali AI, Sheikh IM, Yussuf FM, Adam SM, Hassan OA, Tabowei G, Jimoh A, Mejulu EO, Cheema AY. Systemic Lupus Erythematosus and Cardiovascular Diseases: A Systematic Review. Cureus 2023; 15:e39284. [PMID: 37346216 PMCID: PMC10280490 DOI: 10.7759/cureus.39284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/23/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune condition characterized by multi-organ involvement. The clinical presentation often varies from mild to moderate to severe. The cardiovascular system may also be affected, often portending a poor prognosis for patients. Although the relationship between SLE and cardiovascular disorders has been extensively explored through case reports and literature reviews, few systematic reviews explicitly focusing on this association have been conducted. In light of this, this systematic review aims to analyze the extent of the association between SLE and cardiovascular diseases (CVDs), by exploring the risk of developing CVDs, including myocardial infarction (MI), atherosclerosis, myocarditis, pericarditis and arrhythmias, in SLE patients vs. non-SLE patients. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform the systematic review. A detailed search was done covering the period from March 2003 to March 2023 using three databases: PubMed, Google Scholar, and Cochrane. The PubMed search identified 597 articles, while Google Scholar and Cochrane searches yielded 559 and three articles, respectively. Of the 1159 articles retrieved, we chose eight for final consideration, after excluding papers that did not discuss the role of SLE in CVDs, papers published earlier than 2003, and papers with incomplete data. The eight studies chosen included two narrative reviews, two systematic reviews, and four observational studies. In this systematic review, SLE was proven to have a strong relationship with diverse CVDs, including rare ones scarcely discussed in the literature, such as vasculitis and aortic dissection. All eight of the final papers indicated a connection between SLE and CVDs, based on the systematic analysis of these articles, which revealed that most recent research supports a higher risk of peripheral arterial occlusive disease (PAOD), MI, pericarditis, myocarditis, and other cardiovascular disorders in individuals with SLE. These associations may have certain gray areas, as patient characteristics and comorbidities often affect the extent of illness and long-term prognosis. Larger-scale studies are required to probe this relationship further and research the etiopathogenesis involved in order to improve patient outcomes. The effects of SLE on the heart are, however, unequivocal.
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Affiliation(s)
- Mohammed A Nor
- Internal Medicine, Stamford Hospital/Columbia University Vagelos College of Physicians and Surgeons for Internal Medicine, Stamford City, USA
| | | | - Ahmed Barbarawi
- Internal Medicine, University of Minnesota, Minneapolis, USA
| | | | | | | | | | - Omar A Hassan
- General Practice, Ondokuz Mayis University, Samsun, TUR
| | - Godfrey Tabowei
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abdulmalik Jimoh
- Internal Medicine, Mount Horeb Clinic and Dialysis Center, Warri, NGA
| | | | - Asfand Yar Cheema
- Medicine, Services Hospital, Lahore, PAK
- Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
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7
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Khayata M, Wang TKM, Chan N, Alkharabsheh S, Verma BR, Oliveira GH, Klein AL, Littlejohn E, Xu B. Multimodality Cardiac Imaging in Patients with Systemic Lupus Erythematosus. Curr Probl Cardiol 2023; 48:101048. [PMID: 34774920 DOI: 10.1016/j.cpcardiol.2021.101048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 02/01/2023]
Abstract
Systemic lupus erythematous (SLE) is an autoimmune disease with a wide range of cardiovascular complications. The main manifestations include diseases of the coronary arteries, valves, pericardium, and myocardium. Multimodality cardiovascular imaging techniques are critical for evaluating the extent of cardiac manifestations in SLE patients, which can provide valuable prognostic information. However, their utility has previously not been well defined. This review provides a state-of-the-art update on the cardiovascular manifestations of lupus, as well as the role of multimodality cardiac imaging in guiding management of patients with SLE.
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Affiliation(s)
- Mohamed Khayata
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Tom Kai Ming Wang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas Chan
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Saqer Alkharabsheh
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beni R Verma
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme H Oliveira
- Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Allan L Klein
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emily Littlejohn
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic, Ohio, USA
| | - Bo Xu
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Section of Cardiovascular Imaging, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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8
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Oyarzun A, Parsons S, Bassed R. Myocarditis in the forensic setting. Cardiovasc Pathol 2023; 62:107476. [PMID: 36122893 DOI: 10.1016/j.carpath.2022.107476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/16/2022] [Accepted: 09/11/2022] [Indexed: 12/24/2022] Open
Abstract
Diagnosis of myocarditis as the cause of death in the forensic setting at post-mortem is currently determined by a forensic pathologist. There is no systematic method for diagnosis and thus the determination is subject to inter-observer variability and is often non-reproducible. The primary aim of this study was to investigate the differences in the amount of inflammation between cases where myocarditis was deemed the cause of death, compared to cases where myocardial inflammation was incidentally present at autopsy, but not determined to be the cause of death. Participants were sourced from the Victorian Institute of Forensic Medicine (VIFM) database, from full autopsies conducted on reportable death in Victoria, Australia between the years 2011 and 2021. Cases of fatal myocarditis were significantly more likely to experience infection-like symptoms prior to death, and to be in hospital at the time of death. Histopathological examination revealed fatal cases had a significantly higher inflammatory index compared to the incidental group. Lethal cases were also significantly more likely to have myocyte necrosis, and a diffuse pattern of inflammation. There are significant differences between cases where myocardial inflammation has been determined to be the cause of death and cases where inflammation in the myocardium was an incidental finding. These results could be used in the forensic autopsy to help pathologists determine if inflammation should be considered fatal or incidental.
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Affiliation(s)
- Adele Oyarzun
- Adjunct Associate Professor Sarah Parsons, Prof Richard Bassed, Melbourbe, VIC, Australia.
| | - Sarah Parsons
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourbe, VIC, Australia
| | - Richard Bassed
- Victorian Institute of Forensic Medicine, Department of Forensic Medicine, Monash University, Melbourbe, VIC, Australia
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9
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Guzmán-Martínez G, Marañón C. Immune mechanisms associated with cardiovascular disease in systemic lupus erythematosus: A path to potential biomarkers. Front Immunol 2022; 13:974826. [PMID: 36420265 PMCID: PMC9677819 DOI: 10.3389/fimmu.2022.974826] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/13/2022] [Indexed: 10/29/2023] Open
Abstract
Systemic lupus erythematosus (SLE) patients display an increased risk of cardiovascular disease (CVD). With the improved clinical management of other classical severe manifestation of the disease, CVD is becoming one of the most relevant complications of SLE, and it is an important factor causing morbidity and mortality. Several immune constituents have been shown to be involved in the pathogenesis of atherosclerosis and endothelial damage in SLE patients, including specific circulating cell populations, autoantibodies, and inflammatory mediators. In this review, we summarize the presentation of CVD in SLE and the role of the autoimmune responses present in SLE patients in the induction of atherogenesis, endothelial impairment and cardiac disease. Additionally, we discuss the utility of these immune mediators as early CVD biomarkers and targets for clinical intervention in SLE patients.
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Affiliation(s)
- Gabriela Guzmán-Martínez
- Atrys Health, Madrid, Spain
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
- Department of Cardiology, La Paz University Hospital, IdiPaz, Madrid, Spain
| | - Concepción Marañón
- Department of Genomic Medicine, Pfizer-University of Granada-Andalusian Regional Government Centre for Genomics and Oncological Research (GENYO), Granada, Spain
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10
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Alghareeb R, Hussain A, Maheshwari MV, Khalid N, Patel PD. Cardiovascular Complications in Systemic Lupus Erythematosus. Cureus 2022; 14:e26671. [PMID: 35949751 PMCID: PMC9358056 DOI: 10.7759/cureus.26671] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an auto-immune disease of a relapsing-remitting nature that can cause multiorgan damage depending on several factors, mainly the disease activity. Young age women are the most likely to be affected by the disease and the female-to-male prevalence ratio is approximately 1:10. As the number of SLE patients has been increasing in the last few decades, the annual number of deaths due to the disease and its complications has increased as well, and one of the most important systems to which high mortality is attributed is the cardiovascular system, leading to premature atherosclerosis and other events such as endocarditis and valve disease. In addition to the classical cardiovascular risk factors, studies have found a positive correlation between SLE and other cardio-harmful diseases such as metabolic syndrome and dyslipidemia. Moreover, some of the medications used in the treatment of SLE place a heavy burden on the heart. The article reviews the shared pathophysiology of SLE and cardiovascular disease along with the most common SLE- associated cardiac risks, events, and management.
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11
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Allaoui A, EL OUARRADI A, Jabbouri R, Naitelhou A. Mycophenolate Mofetil Use in Severe Myocarditis Complicating Systemic Lupus. Cureus 2022; 14:e25789. [PMID: 35812561 PMCID: PMC9270891 DOI: 10.7759/cureus.25789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiac involvement represents an increasingly frequent complication in systemic lupus, with pericarditis being the most classic cardiac manifestation. However, the most severe and fatal form seems to be myocarditis. We present the case of a patient with systemic lupus complicated by cardiogenic shock secondary to troponin-negative acute myopericarditis and successfully treated with mycophenolate mofetil and corticosteroid therapy. A 33-year-old woman with no past medical history presented with asthenia and inflammatory arthralgia. She was admitted in June 2021 for acute heart failure. Transthoracic cardiac ultrasound showed dilated cardiomyopathy with global hypokinesis (20-25% of ejection fraction) and right ventricular dysfunction without significant mitral and aortic valve disease. She had raised proBNP (pro-brain natriuretic peptide), low troponin, normochromic normocytic anemia at 10.4 g/dL, positive direct Coombs, lymphopenia at 460/mm3, serum creatinine at 23.9 mg/L, and proteinuria/creatininuria 2.48 g/g. Cardiac magnetic resonance imaging (CMR) suggested the diagnosis of myopericarditis. The etiological assessment did not identify an infectious, toxic, or medicinal cause. The clinical picture suggested the possibility of an autoimmune disease. The patient presented with lesions suggestive of cutaneous vasculitis, with oral ulcers with polyarthritis. The autoimmune workup showed anti-nuclear antibodies at 1:1,280, anti-native DNA antibodies at 210 IU/mL (normal < 10 IU/mL), and positive anti-SM Abs. The diagnosis of lupus myopericarditis complicated by cardiogenic shock was made, which was associated with acute renal impairment. The patient was initiated on heart failure medications along with corticosteroids and mycophenolate mofetil. On day 15, the left ventricular ejection fraction improved to 45-50%, with clinical improvement in signs of heart failure and general condition. The existence of myopericarditis without obvious etiology, especially when there are extra-cardiac signs such as skin and joint involvement, should lead us to look for systemic lupus in order to start etiological treatment in addition to cardiac medical treatment. Until now, there is no standard treatment for lupus myocarditis, but the use of mycophenolate mofetil seems to be a promising treatment.
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12
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Chen YJ, Lin YJ, Guo MMH. Pediatric Lupus Presenting as Pulmonary Hypertension, Myocarditis, and Massive Pericardial Effusion in an 11-Year-Old Girl: A Case Report and Literature Review. Front Pediatr 2022; 10:772422. [PMID: 35155304 PMCID: PMC8826687 DOI: 10.3389/fped.2022.772422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/03/2022] [Indexed: 12/02/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that may cause vital organ damage. Although not rare for child-onset SLE to have cardiovascular or pulmonary involvement, myocarditis, and pulmonary hypertension are infrequent features and can be life-threatening. In this case report, we describe an 11-year-old girl with SLE who initially presented with fulminant myocarditis pulmonary hypertension, and massive pericardial effusion. Initial immunosuppressive therapy with methylprednisolone pulse therapy, and IVIG were administered, followed by cyclophosphamide, which was ultimately successful, with no residual pulmonary hypertension and no recurrence of myocarditis for over 3 years after the initial episode. Our case highlights the need for clinicians to be aware of systemic lupus erythematosus as a possible diagnostic entity in pediatric patients with severe myocarditis or pulmonary hypertension. Aggressive immunosuppressive therapy should be strongly considered in such cases, as it may lead to good short-term and long-term outcomes.
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Affiliation(s)
- Yu-Jhen Chen
- Department of Pediatric Allergy Immunology and Rheumatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Jui Lin
- Department of Pediatric Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mindy Ming-Huey Guo
- Department of Pediatric Allergy Immunology and Rheumatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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13
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Hoffmann T, Oelzner P, Busch M, Franz M, Teichgräber U, Kroegel C, Schulze PC, Wolf G, Pfeil A. Organ Manifestation and Systematic Organ Screening at the Onset of Inflammatory Rheumatic Diseases. Diagnostics (Basel) 2021; 12:67. [PMID: 35054234 PMCID: PMC8774450 DOI: 10.3390/diagnostics12010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/20/2021] [Accepted: 12/25/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Inflammatory rheumatic diseases (IRD) are often associated with the involvement of various organs. However, data regarding organ manifestation and organ spread are rare. To close this knowledge gap, this cross-sectional study was initiated to evaluate the extent of solid organ manifestations in newly diagnosed IRD patients, and to present a structured systematic organ screening algorithm. MATERIALS AND METHODS The study included 84 patients (63 women, 21 men) with newly diagnosed IRD. None of the patients received any rheumatic therapy. All patients underwent a standardised organ screening programme encompassing a basic screening (including lungs, heart, kidneys, and gastrointestinal tract) and an additional systematic screening (nose and throat, central and peripheral nervous system) on the basis of clinical, laboratory, and immunological findings. RESULTS Represented were patients with connective tissue diseases (CTD) (72.6%), small-vessel vasculitis (16.7%), and myositis (10.7%). In total, 39 participants (46.5%) had one or more organ manifestation(s) (one organ, 29.7%; two organs, 10.7%; ≥three organs, 6.0%). The most frequently involved organs were the lungs (34.5%), heart (11.9%), and kidneys (8.3%). Lastly, a diagnostic algorithm for organ manifestation was applied. CONCLUSION One-half of the patients presented with a solid organ involvement at initial diagnosis of IRD. Thus, in contrast to what has been described in the literature, organ manifestations were already present in a high proportion of patients at the time of diagnosis of IRD rather than after several years of disease. Therefore, in IRD patients, systematic organ screening is essential for treatment decisions.
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Affiliation(s)
- Tobias Hoffmann
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (P.O.); (M.B.); (G.W.); (A.P.)
| | - Peter Oelzner
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (P.O.); (M.B.); (G.W.); (A.P.)
| | - Martin Busch
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (P.O.); (M.B.); (G.W.); (A.P.)
| | - Marcus Franz
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (M.F.); (P.C.S.)
| | - Ulf Teichgräber
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany;
| | - Claus Kroegel
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (M.F.); (P.C.S.)
| | - Paul Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (M.F.); (P.C.S.)
| | - Gunter Wolf
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (P.O.); (M.B.); (G.W.); (A.P.)
| | - Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany; (P.O.); (M.B.); (G.W.); (A.P.)
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14
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Noda S, Hasegawa H, Tokura M, Mizoguchi F, Kohsaka H. A Case of Systemic Lupus Erythematosus Presenting With Thrombotic Microangiopathy-Induced Cardiomyopathy. J Clin Rheumatol 2021; 27:S847-S848. [PMID: 32084075 DOI: 10.1097/rhu.0000000000001353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Seiji Noda
- From the Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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15
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Țăpoi L, Ureche C, Clement A, Ailoaei Ș, Sascău RA. What can hide behind an "idiopathic" dilated cardiomyopathy? Arch Clin Cases 2021; 7:28-33. [PMID: 34754924 PMCID: PMC8565682 DOI: 10.22551/2020.27.0702.10169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Myocarditis is an infectious–inflammatory disease with viral infections being one of the most common infectious cause. When it is superimposed to an individual genetic background, myocarditis may progress into a chronic heart muscle disorder, most often dilated cardiomyopathy (DCM), with a natural history similar to classic forms of genetic or idiopathic dilated cardiomyopathies. We present the case of a 30-year-old patient, with a persistent infectious episode in the last 8 weeks, pain and swelling in the large joints. At admission the patient had fever, tachycardia and a grade 2/6 systolic mitral murmur. Laboratory findings revealed inflammatory syndrome, hepatocytolysis syndrome and microalbuminuria. The electrocardiogram (ECG) showed possible right atrial tachycardia. The echocardiography revealed a globally enlarged heart with reduced ejection fraction and diffuse hypokinesia. When discussing the etiology of the DCM, the following were taken into consideration: a tachycardiomyopathy, ischemic etiology, genetic component, autoimmune etiology (elevated anti-Ro titer), and myocarditis. The diagnosis of myocarditis was confirmed by the cardiac magnetic resonance imaging which showed diffuse fibrosis of the interstitial space and an important increase of the extracellular volume. This case is distinguished by a particular immunological panel requiring dynamic monitoring in order to diagnose a possible associated autoimmune pathology.
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Affiliation(s)
- Laura Țăpoi
- "Prof. Dr. George I.M. Georgescu" Cardiovascular Diseases Institute, Iasi.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Carina Ureche
- "Prof. Dr. George I.M. Georgescu" Cardiovascular Diseases Institute, Iasi.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandra Clement
- "Prof. Dr. George I.M. Georgescu" Cardiovascular Diseases Institute, Iasi.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Ștefan Ailoaei
- "Prof. Dr. George I.M. Georgescu" Cardiovascular Diseases Institute, Iasi.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Radu Andy Sascău
- "Prof. Dr. George I.M. Georgescu" Cardiovascular Diseases Institute, Iasi.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
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16
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Lee SY, Park JH, Shin DH, Kim T, Lim S. Fatal Myopericarditis in a Patient With Lupus Erythematosus Supported by Extracorporeal Membrane Oxygenation: A Case Report. JOURNAL OF RHEUMATIC DISEASES 2021; 28:165-170. [PMID: 37475997 PMCID: PMC10324896 DOI: 10.4078/jrd.2021.28.3.165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/13/2021] [Accepted: 05/15/2021] [Indexed: 07/22/2023]
Abstract
Systemic lupus erythematosus (SLE) may occur in any organ. In patients with SLE, myocarditis is extremely rare and potentially life-threatening. Herein, we report on a patient with lupus myocarditis, diagnosed by myocardial biopsy, immunologic tests, and clinical manifestations. Our findings suggest that securing time for diagnosis via extracorporeal membrane oxygenation and other intensive care is helpful for obtaining a good prognosis.
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Affiliation(s)
- Soo Yong Lee
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Ji Hye Park
- Division of Rheumatology, Department of Internal Medicine, Daedong Hosipital, Busan, Korea
| | - Dong Hoon Shin
- Department of Pathology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Taehwa Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seungjin Lim
- Division of Infectious Disease, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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17
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Tavakol DN, Fleischer S, Vunjak-Novakovic G. Harnessing organs-on-a-chip to model tissue regeneration. Cell Stem Cell 2021; 28:993-1015. [PMID: 34087161 DOI: 10.1016/j.stem.2021.05.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Tissue engineering has markedly matured since its early beginnings in the 1980s. In addition to the original goal to regenerate damaged organs, the field has started to explore modeling of human physiology "in a dish." Induced pluripotent stem cell (iPSC) technologies now enable studies of organ regeneration and disease modeling in a patient-specific context. We discuss the potential of "organ-on-a-chip" systems to study regenerative therapies with focus on three distinct organ systems: cardiac, respiratory, and hematopoietic. We propose that the combinatorial studies of human tissues at these two scales would help realize the translational potential of tissue engineering.
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Affiliation(s)
| | - Sharon Fleischer
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, NY; Department of Medicine, Columbia University, New York, NY.
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18
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Zhan RZ, Rao L, Chen Z, Strash N, Bursac N. Loss of sarcomeric proteins via upregulation of JAK/STAT signaling underlies interferon-γ-induced contractile deficit in engineered human myocardium. Acta Biomater 2021; 126:144-153. [PMID: 33705988 DOI: 10.1016/j.actbio.2021.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 12/19/2022]
Abstract
The level of circulating interferon-γ (IFNγ) is elevated in various clinical conditions including autoimmune and inflammatory diseases, sepsis, acute coronary syndrome, and viral infections. As these conditions are associated with high risk of myocardial dysfunction, we investigated the effects of IFNγ on 3D fibrin-based engineered human cardiac tissues ("cardiobundles"). Cardiobundles were fabricated from human pluripotent stem cell-derived cardiomyocytes, exposed to 0-20 ng/ml of IFNγ on culture days 7-14, and assessed for changes in tissue structure, viability, contractile force and calcium transient generation, action potential propagation, cytokine secretion, and expression of select genes and proteins. We found that application of IFNγ induced a dose-dependent reduction in contractile force generation, deterioration of sarcomeric organization, and cardiomyocyte disarray, without significantly altering cell viability, action potential propagation, or calcium transient amplitude. At molecular level, the IFNγ-induced structural and functional deficits could be attributed to altered balance of pro- and anti-inflammatory cytokines, upregulation of JAK/STAT signaling pathway (JAK1, JAK2, and STAT1), and reduced expression of myosin heavy chain, myosin light chain-2v, and sarcomeric α-actinin. Application of clinically used JAK/STAT inhibitors, tofacitinib and baricitinib, fully prevented IFNγ-induced cardiomyopathy, confirming the critical roles of this signaling pathway in inflammatory cardiac disease. Taken together, our in vitro studies in engineered myocardial tissues reveal direct adverse effects of pro-inflammatory cytokine IFNγ on human cardiomyocytes and establish the foundation for a potential use of cardiobundle platform in modeling of inflammatory myocardial disease and therapy. STATEMENT OF SIGNIFICANCE: Various inflammatory and autoimmune diseases including rheumatoid arthritis, sepsis, lupus erythematosus, Chagas disease, and others, as well as viral infections including H1N1 influenza and COVID-19 show increased systemic levels of a pro-inflammatory cytokine interferon-γ (IFNγ) and are associated with high risk of heart disease. Here we explored for the first time if chronically elevated levels of IFNγ can negatively affect structure and function of engineered human heart tissues in vitro. Our studies revealed IFNγ-induced deterioration of myofibrillar organization and contractile force production in human cardiomyocytes, attributed to decreased expression of multiple sarcomeric proteins and upregulation of JAK/STAT signaling pathway. FDA-approved JAK inhibitors fully blocked the adverse effects of IFNγ, suggesting a potentially effective strategy against human inflammatory cardiomyopathy.
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Abel D, Ardoin SP, Gorelik M. The potential role of Colchicine in preventing coronary vascular disease in childhood-onset lupus: a new view on an old drug. Pediatr Rheumatol Online J 2021; 19:15. [PMID: 33593369 PMCID: PMC7885423 DOI: 10.1186/s12969-021-00504-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/08/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Patients with systemic lupus erythematous have a significantly increased risk of cardiovascular disease, which is not fully explained by traditional cardiovascular disease risk factors. Despite increasing life expectancy in patients with systemic lupus erythematous, mortality due to cardiovascular disease, the major cause of death in these patients, has not changed. Children with lupus suffer from more aggressive disease compared to their adult counterparts, and there is a growing concern for their increased risk of cardiovascular disease as they age. BODY: There is an unmet need for therapies to address the increased risk of cardiovascular disease in childhood-onset lupus. Colchicine has many anti-inflammatory and cardiovascular protective properties, including inhibition of IL-1β and IL-18 activity, key proinflammatory cytokines that are predictive of future adverse cardiovascular events. In the Colchicine Cardiovascular Outcomes Trial (COLCOT), colchicine was recently found to have significant benefit with minimal risk in adults with previous myocardial infarction for prevention of secondary vascular disease. While adult studies are promising, no studies have been conducted in pediatric patients to investigate colchicine's potential for cardiovascular protection in children and adolescents with lupus. CONCLUSIONS Studies investigating colchicine's potential role for cardiovascular protection are needed in pediatric patients with systemic lupus erythematous.
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Affiliation(s)
- Dori Abel
- Department of Pediatrics, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, 630 W. 168th Street, New York, NY, 10032-3702, USA.
| | - Stacy P. Ardoin
- grid.261331.40000 0001 2285 7943Department of Medicine, Division of Rheumatology and Immunology, The Ohio State University, 370 W. 9th Ave, Columbus, OH 43210 USA ,grid.240344.50000 0004 0392 3476Department of Rheumatology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205 USA
| | - Mark Gorelik
- grid.21729.3f0000000419368729Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032-3702 USA
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20
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Smith C, Guglin M, Dougherty RE, Rao RA. A Unique Case of Systemic Lupus Erythematosus Myocarditis Complicated by Plasmapheresis-Responsive Cardiogenic Shock. JACC Case Rep 2020; 2:2376-2380. [PMID: 34317175 PMCID: PMC8304555 DOI: 10.1016/j.jaccas.2020.09.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
A 25-year-old woman with systemic lupus erythematosus complicated by biventricular failure with a history of multiple admissions presented with cardiogenic shock unresponsive to steroids, intravenous immunoglobulin, cyclophosphamide, and required extra-corporeal membrane oxygenation. Left ventricular function eventually recovered after plasmapheresis. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Carson Smith
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Maya Guglin
- Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel E Dougherty
- Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Roopa A Rao
- Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, Indianapolis, Indiana, USA
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21
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Mohanty B, Sunder A. Lupus myocarditis-A rare case. J Family Med Prim Care 2020; 9:4441-4443. [PMID: 33110880 PMCID: PMC7586557 DOI: 10.4103/jfmpc.jfmpc_716_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 07/01/2020] [Indexed: 11/13/2022] Open
Abstract
Myocarditis in patients of systemic lupus erythematosus is extremely rare and is potentially life threatening. This may be the first presentation of the disease. Here, we report a patient who presented with features of heart failure and was later diagnosed to have SLE.
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Affiliation(s)
- Bijaya Mohanty
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Ashok Sunder
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
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22
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Gawalkar AA, Bahl A, Ahluwalia J, Sood A, Sharma A, Sharma S, Dhir V. Prevalence of antiphospholipid antibodies in patients with overt myocardial dysfunction in systemic lupus erythematosus. A case-control study. Lupus 2020; 29:1503-1508. [DOI: 10.1177/0961203320947784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Small case-series have reported overt myocardial dysfunction to be associated with positive antiphospholipid antibodies in patients of systemic lupus erythematosus (SLE). However, there is no case-control study that has examined this association. Methods This case-control study recruited patients of SLE (fulfilling SLICC criteria) with overt myocardial dysfunction as cases and those without this as controls. Overt myocardial dysfunction was defined by echocardiography as global left ventricular dysfunction and reduced ejection fraction (<50%). Those patients with a prior diagnosis of anti-phospholipid antibody syndrome, coronary artery disease, rheumatic heart disease or severe pulmonary artery hypertension were excluded. Antibodies tested included lupus anticoagulant, anticardiolipin antibodies (IgM and IgG) and anti-beta 2 glycoprotein 1 antibodies (IgM and IgG). Patients with positive tests underwent repeat testing for persistent positivity after 12 weeks. Results This study included 51 patients (21 cases and 30 controls) having a mean (SD) age of 33 (13.3) years, and disease duration (median, IQR) of 28 months (12−38 months). The mean ejection fraction of cases was 31.7 (9.3)% while that of controls was 55.7 (1.7)% (p = 0.03). The frequency (percentage) of positive antiphospholipid antibodies was not significantly different between cases and controls (43%, 40%, p = 0.8). The frequency (percentage) of anti-cardiolipin antibody was also not significant between the groups (38%, 37%, p = 0.57). Serositis and leucopenia were more prevalent in SLE patients with myocardial dysfunction (p = 0.005). Conclusion This study did not find any significant association of anti-phospholipid antibodies with overt myocardial dysfunction in patients of SLE.
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Affiliation(s)
| | - Ajay Bahl
- Department of Cardiology, PGIMER, Chandigarh, India
| | | | - Ashwani Sood
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Shefali Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, PGIMER, Chandigarh, India
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Shemesh E, Abu Akel M, Feld J, Zisman D, Hijaze N, Hamdan A, Zissman K. Lupus myocarditis in an octogenarian patient—a case report. Oxf Med Case Reports 2020; 2020:omaa094. [PMID: 33133626 PMCID: PMC7583416 DOI: 10.1093/omcr/omaa094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/13/2020] [Accepted: 08/14/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Lupus myocarditis is a relatively rare manifestation of systemic lupus erythematosus. The majority of patients who experience myocardial involvement are females of young age. Here, we report a case of an 87-year-old male who was hospitalized because of perimyocarditis 2 weeks after undergoing percutaneous coronary intervention. Despite standard therapy his condition worsened, biomarkers and inflammation indices remained elevated, and pericardial effusion accumulated. The use of cardiac magnetic resonance (CMR) imaging, along with thorough history taking and testing for relevant antibodies allowed to establish the unusual diagnosis of lupus myocaridits. We demonstrate that lupus myocarditis may occur even in elderly males, as supported by characteristic CMR features.
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Affiliation(s)
- Elad Shemesh
- Department of Cardiovascular medicine, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
| | - Mahmood Abu Akel
- Department of Cardiovascular medicine, Carmel Medical Center, Haifa, Israel
| | - Joy Feld
- Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
- Rheumatology unit, Carmel Medical Center, Haifa, Israel
| | - Devy Zisman
- Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
- Rheumatology unit, Carmel Medical Center, Haifa, Israel
| | - Nizar Hijaze
- Rheumatology unit, Carmel Medical Center, Haifa, Israel
| | - Ashraf Hamdan
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Keren Zissman
- Department of Cardiovascular medicine, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
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Liu L, Dong Y, Gao H, Yao D, Zhang R, Zheng T, Jin Y, Lv B, Tian Y. Cardiogenic shock as the initial manifestation of systemic lupus erythematosus. ESC Heart Fail 2020; 7:1992-1996. [PMID: 32515553 PMCID: PMC7373915 DOI: 10.1002/ehf2.12806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/22/2020] [Accepted: 05/14/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiogenic shock as the initial manifestation of systemic lupus erythematosus (SLE) is an uncommon but catastrophic complication. Because of the lack of typical clinical features, the diagnosis of the disease is challenging. This case report describes a 47‐year‐old female admitted to the emergency room in refractory cardiogenic shock with dilative cardiomyopathy and a left ventricular ejection fraction (LVEF) of 25.6% of unknown origin. The patient responded poorly to the initial tries of stabilization, and the clinical status continued to deteriorate. Venous–arterial extracorporeal membrane oxygenation (V‐A ECMO) was applied to maintain hemodynamic stability. Coronary angiography revealed no obvious stenosis of the coronary artery. Evidence of virus infection was negative. After requestioning about medical history in detail, Reynaud's phenomenon was shown. SLE was suspected. A complete autoimmune laboratory workup was completed and found the positive result of antinuclear antibodies, anti‐double‐stranded DNA antibodies, anti‐phospholipid antibodies, and low C3 and C4. The patient also presented with pericardial effusion and the PLTs <100 000/mm3. SLE was confirmed according to the 2019 EULAR/ACR criteria. When the diagnosis was established, the immunotherapy was initiated. As a result, the patient underwent a quick recovery and achieved good outcomes. In conclusion, early diagnosis and timely application of immunotherapy is the key to treatment lupus myocarditis. Advanced mechanical support may play a necessary role when patient is in critical situation. For middle‐aged female patients presenting with unexplained cardiogenic shock, lupus myocarditis should be considered in the differential diagnosis. In addition, the 2019 EULAR/ACR criteria provide a new, fitting tool for the diagnosis, which is conducive to the earlier and more accurate diagnosis of SLE.
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Affiliation(s)
- Liang Liu
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Yanling Dong
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Hengbo Gao
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Dongqi Yao
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Rui Zhang
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Tuokang Zheng
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Yingli Jin
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Baopu Lv
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Yingping Tian
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
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25
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Chang JC, Xiao R, Knight AM, Kimmel SE, Mercer-Rosa LM, Weiss PF. A population-based study of risk factors for heart failure in pediatric and adult-onset systemic lupus erythematosus. Semin Arthritis Rheum 2020; 50:527-533. [PMID: 32446021 PMCID: PMC7492402 DOI: 10.1016/j.semarthrit.2020.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The increased relative risk of heart failure (HF) from systemic lupus erythematosus (SLE) is greatest at younger ages, but the etiology remains unclear. We identified risk factors for HF in children and adults with SLE and evaluated associations between SLE manifestations and HF. METHODS Incident SLE cases without preceding HF were identified using Clinformatics DataMart® (OptumInsight, Eden Prairie, MN) US claims data (2000-2015), and categorized by age of SLE onset (children 5-17, young adults 18-24, adults 25-44 years old). The primary outcome was the first HF ICD-9-CM diagnosis code (428.x), categorized as early-onset (< 6 months) or delayed-onset. Multivariable logistic regression was used to identify factors associated with early or delayed-onset HF. Cox proportional hazards regression was used to identify time-dependent associations between the onset of SLE manifestations and incident HF. RESULTS There were 523 (2.3%) HF cases among 1,466 children, 2,163 young adults and 19,349 adults age 25-44 with SLE. HF in children and young adults was early-onset in 50% and 60% of cases, respectively, compared to 35% of cases in adults 25-44 years old. There was a temporal association between incident myopericarditis and valvular disease diagnoses and early-onset HF, whereas nephritis and hypertension were more strongly associated with delayed-onset HF. Black race remained independently associated with a 1.5-fold increased HF risk at any time. CONCLUSION Hypertension remains an important traditional CV risk factor across all ages and should be managed aggressively even in younger patients with SLE. Cardiac dysfunction due to acute cardiac manifestations of SLE may contribute to the very high relative incidence of early HF diagnoses among younger SLE patients. Therefore, future prospective studies will need to address heterogeneity in the types and severity of heart failure in order to determine etiology and which patients should be monitored.
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Affiliation(s)
- Joyce C Chang
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Rui Xiao
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrea M Knight
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada; SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen E Kimmel
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura M Mercer-Rosa
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pamela F Weiss
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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26
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Herath HMMTB, Kulatunga A. Systemic lupus erythematosus presenting with status epilepticus and acute cardiomyopathy with acute heart failure: case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020; 56:15. [PMID: 32435128 PMCID: PMC7223658 DOI: 10.1186/s41983-020-0149-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction Systemic lupus erythematosus is a connective tissue disorder, which causes complex multi organ involvement. Neurological and cardiac manifestations have been well noted but complications such as status epilepticus and acute myocarditis with heart failure at presentation remains uncommon. Case description A 15-year-old, previously healthy, South Asian, Sri Lankan female presented with status epilepticus and the seizures only responded to intravenous midazolam and thiopentone sodium. On the fourth day, she developed tachycardia and shortness of breath and was found to have cardiomyopathy with heart failure with an ejection fraction 40%. Along with a positive urinary sediment, a positive ANA with a very high level of ds-DNA and low C3 and C4 levels confirmed our suspicion of systemic lupus erythematosus. Discussion and evaluation Systemic lupus erythematosus presents in a variety of clinical presentations and the spectrum may range from unique to ubiquitous. Clinicians should have a high index of suspicion specially when encountering atypical presentations with multi-organ involvement, especially when patients tend to be young females. Status epilepticus and myocarditis are uncommon manifestations of systemic lupus erythematosus, and should be appreciated early, as if inappropriately managed would have a deleterious impact on mortality and morbidity.
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Harano Y, Ishikawa Y, Hattori K, Ichinose M, Tomofuji Y, Okano H, Owada G, Kimura Y, Nanao T, Fujimoto J, Nishizawa H, Iioka Y, Osada J, Fujiwara M, Kita Y. A case of complete atrioventricular block in secondary hemophagocytic syndrome/hemophagocytic lymphohistiocytosis recovered by plasma exchange and cytokine absorbing therapy with AN69ST continuous hemodiafiltration. Immunol Med 2020; 43:171-178. [PMID: 32374660 DOI: 10.1080/25785826.2020.1761145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
We report a case of incipient systemic lupus erythematosus (SLE) that rapidly progressed to complete atrioventricular block (cAVB). A 20-year-old man was admitted with facial erythema, painless oral aphtha, polyarthritis, and myalgia of each extremity. On admission, he developed first-degree atrioventricular block, pericarditis, pleuritis, renal failure, hemophagocytic lymphohistiocytosis, neurophychiatric SLE (left cerebellar infarction), and Staphylococcus aureus bacteremia. He was subsequently diagnosed with SLE based on several positive findings on immunological tests (including positive for antinuclear antibody). Despite immediate glucocorticoid pulse therapy and plasma exchange (PE) along with antibiotic, he developed cAVB that required temporary pacing on day 2. Because it was thought that hypercytokinemia exacerbated pericarditis, which progressed to myocarditis and cAVB, we decided to PE and cytokine-adsorbing therapy with AN69ST-continuous hemodiafiltration (CHDF). Other than renal failure, his organ dysfunctions improved with the multidisciplinary therapy. CAVB improved and temporary pacing was no longer required on day 11. Even a first-degree atrioventricular block can rapidly progress to cAVB; therefore, strict attention to electrocardiogram is necessary in severe SLE cases. When presenting with organ dysfunctions caused by hypercytokinemia such as severe SLE cases or SLE with severe infection cases, use of the combination of PE and AN69ST-CHDF might be beneficial.
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Affiliation(s)
- Yoshihiro Harano
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yuichi Ishikawa
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Koto Hattori
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Mami Ichinose
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
| | | | - Hiroshi Okano
- Department of Central Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Gen Owada
- Department of Central Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yasuhiro Kimura
- Department of Central Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Taikan Nanao
- Department of Central Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Junichi Fujimoto
- Department of Central Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Hideo Nishizawa
- Department of Central Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yuto Iioka
- Department of Cardiology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Jun Osada
- Department of Cardiology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Michio Fujiwara
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yasuhiko Kita
- Department of Rheumatology, Yokohama Rosai Hospital, Yokohama, Japan
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Gartshteyn Y, Tamargo M, Fleischer S, Kapoor T, Li J, Askanase A, Winchester R, Geraldino-Pardilla L. Endomyocardial biopsies in the diagnosis of myocardial involvement in systemic lupus erythematosus. Lupus 2020; 29:199-204. [PMID: 31924147 DOI: 10.1177/0961203319897116] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is considered the gold standard for diagnosing myocardial involvement in most inflammatory conditions, including systemic lupus erythematosus (SLE). However, EMBs are rarely performed, and most of the myocardial histopathology reports in SLE consist of postmortem data. We therefore sought to describe the histopathologic findings of contemporary EMBs in SLE performed in clinical practice. METHODS A retrospective review of histopathology reports from SLE patients who underwent EMB from 1994 to 2017 was performed. A total of 41 SLE patients had cardiac pathology reports. Of these, 11 histopathology reports were EMBs, and the remaining were valvular specimens. RESULTS A total of 11 SLE EMBs were reviewed. It was found that 45% of the patients had hypertension, 27% had coronary artery disease, 9% had hyperlipidemia, and 36% had end-stage renal disease. None had diabetes or smoked. The mean left ventricular ejection fraction was 37%. On histopathology, 10 had mild interstitial fibrosis, 9 had myocyte hypertrophy, 3 had organized blood clots, and 3 had a mild infiltration of lymphocytes and macrophages without clear evidence of myocarditis. None had vasculitis, endocarditis, ischemia, amyloid deposition, or lamellar or curvilinear inclusions. CONCLUSION EMBs are rarely performed in SLE. In this case series, nonspecific interstitial fibrosis and myocyte hypertrophy were the most common findings, suggesting EMBs have limited value in the diagnosis of cardiac involvement in SLE and rather rule out competing conditions. These data support the need for diagnostic methods with high sensitivity and specificity for SLE heart disease.
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Affiliation(s)
- Y Gartshteyn
- Division of Rheumatology, Columbia University, New York, USA
| | - M Tamargo
- Department of Biomedical Engineering, Columbia University, New York, USA
| | - S Fleischer
- Department of Biomedical Engineering, Columbia University, New York, USA
| | - T Kapoor
- Division of Rheumatology, Columbia University, New York, USA
| | - J Li
- Department of Biomedical Informatics, Columbia University, New York, USA
| | - A Askanase
- Division of Rheumatology, Columbia University, New York, USA
| | - R Winchester
- Division of Rheumatology, Columbia University, New York, USA
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29
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Mavrogeni SI, Markousis-Mavrogenis G, Aggeli C, Tousoulis D, Kitas GD, Kolovou G, Iliodromitis EK, Sfikakis PP. Arrhythmogenic Inflammatory Cardiomyopathy in Autoimmune Rheumatic Diseases: A Challenge for Cardio-Rheumatology. Diagnostics (Basel) 2019; 9:diagnostics9040217. [PMID: 31835542 PMCID: PMC6963646 DOI: 10.3390/diagnostics9040217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/04/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022] Open
Abstract
Ventricular arrhythmia (VA) in autoimmune rheumatic diseases (ARD) is an expression of autoimmune inflammatory cardiomyopathy (AIC), caused by structural, electrical, or inflammatory heart disease, and has a serious impact on a patient’s outcome. Myocardial scar of ischemic or nonischemic origin through a re-entry mechanism facilitates the development of VA. Additionally, autoimmune myocardial inflammation, either isolated or as a part of the generalized inflammatory process, also facilitates the development of VA through arrhythmogenic autoantibodies and inflammatory channelopathies. The clinical presentation of AIC varies from oligo-asymptomatic presentation to severe VA and sudden cardiac death (SCD). Both positron emission tomography (PET) and cardiovascular magnetic resonance (CMR) can diagnose AIC early and be useful tools for the assessment of therapies during follow-ups. The AIC treatment should be focused on the following: (1) early initiation of cardiac medication, including ACE-inhibitors, b-blockers, and aldosterone antagonists; (2) early initiation of antirheumatic medication, depending on the underlying disease; and (3) potentially implantable cardioverter–defibrillator (ICD) and/or ablation therapy in patients who are at high risk for SCD.
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Affiliation(s)
- Sophie I. Mavrogeni
- Onassis Cardiac surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.K.)
- Correspondence:
| | | | - Constantina Aggeli
- First Cardiac Clinic, Hippokration University Hospital, 17674 Athens, Greece; (C.A.); (D.T.)
| | - Dimitris Tousoulis
- First Cardiac Clinic, Hippokration University Hospital, 17674 Athens, Greece; (C.A.); (D.T.)
| | - George D. Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester M13 9PT, UK;
| | - Genovefa Kolovou
- Onassis Cardiac surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.K.)
| | | | - Petros P. Sfikakis
- First Department of Propeudeutic and Internal medicine, Laikon Hospital, Athens University Medical School, 17674 Athens, Greece;
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30
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Schultz M, Wimberly K, Guglin M. Systemic lupus and catastrophic antiphospholipid syndrome manifesting as cardiogenic shock. Lupus 2019; 28:1350-1353. [PMID: 31451079 DOI: 10.1177/0961203319871099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In this case series we present two young female patients presenting in the peripartum period with cardiogenic shock. Both patients had underlying autoimmune diseases, one with systemic lupus erythematosus (SLE) and the other with antiphospholipid syndrome (APS). In both cases cardiogenic shock was a direct manifestation of their autoimmune condition, and with prompt diagnosis and management both patients were able to recover. This case series illustrates the importance of early recognition of cardiogenic shock as a rare manifestation both of SLE and APS.
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Affiliation(s)
- M Schultz
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - K Wimberly
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - M Guglin
- Gill Heart Institute, University of Kentucky, Lexington, KY, USA
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31
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Ando T, Yamasaki Y, Takakuwa Y, Iida H, Asari Y, Suzuki K, Uchida M, Kotoku N, Tanabe Y, Chosokabe M, Takahashi M, Suzuki K, Akashi YJ, Yamada H, Kawahata K. Concurrent onset of acute lupus myocarditis, pulmonary arterial hypertension and digital gangrene in a lupus patient: a possible role of vasculitis to the rare disorders. Mod Rheumatol Case Rep 2019; 4:21-27. [PMID: 33086967 DOI: 10.1080/24725625.2019.1650698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute lupus myocarditis and pulmonary arterial hypertension (PAH) are rare complications associated with systemic lupus erythematosus (SLE). No previous reports have shown the coexistence of these disorders. Here we present a 41-year-old patient with SLE who concurrently developed severe acute lupus myocarditis and PAH with digital gangrene as an initial manifestation. Acute lupus myocarditis and PAH were successfully treated with prednisolone and intravenous cyclophosphamide pulse therapy (600-700 mg × 6) along with anticoagulant therapy. Catheter-directed thrombolysis was required for digital gangrene caused by vasculitis. Concurrent development of these rare disorders may represent a common mechanism such vasculitis as an underlining cause of SLE.
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Affiliation(s)
- Takayasu Ando
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshioki Yamasaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yukiko Takakuwa
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Harunobu Iida
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yusa Asari
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kanako Suzuki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Marina Uchida
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Nozomi Kotoku
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuhiro Tanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Motohiro Chosokabe
- Division of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahide Takahashi
- Division of Radiology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Kengo Suzuki
- Division of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihiro J Akashi
- Division of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidehiro Yamada
- Medical Center for Rheumatic Diseases, Seirei-Yokohama Hospital, Yokohama, Japan
| | - Kimito Kawahata
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Systemic Lupus Erythematosus Presenting as Myopericarditis with Acute Heart Failure: A Case Report and Literature Review. Case Rep Rheumatol 2019; 2019:6173276. [PMID: 31428503 PMCID: PMC6681595 DOI: 10.1155/2019/6173276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/07/2019] [Accepted: 07/14/2019] [Indexed: 01/31/2023] Open
Abstract
Acutely decompensated dilated cardiomyopathy in a middle-aged patient without the typical risk factor profile presents a clinical dilemma. While cardiomyopathy is a known aspect of systemic lupus erythematosus (SLE), initial clinical presentation as decompensated dilated cardiomyopathy (DCM) is exceedingly rare in the literature. We share the case of a 49-year-old African-American female with no past medical history who presented with overt heart failure of 4 weeks evolution. Workup showed acute onset decompensated dilated cardiomyopathy, with a serologic profile compatible with SLE. She responded well to immunosuppressive steroid therapy. Literature review for SLE presenting as dilated cardiomyopathy with acute heart failure revealed a paucity of clinical evidence and consensus. Therefore, a comprehensive review of case reports was undertaken. A total of 10 cases were identified. Patients were 90% female and averaged 31 years of age. Dyspnea was the most common clinical presentation, and dilated cardiomyopathy with severely compromised left ventricular function was universally appreciated. Clinical presentation to diagnosis averaged 2 weeks. Immunosuppressive therapy regimens were universally employed; however, the regimens varied significantly. High-dose steroid therapy was most commonly used, and clinical and functional recovery was reported in 90% of individual case reports. Within the limited evidence and experience of therapeutic approaches, the efficacy of different singular or combined therapy is based solely on anecdotal case reports. Given the near-complete response to a short course of high-dose steroid therapy as much in the clinical recovery as in the resolution of DCM, the limited evidence based on review of these observational case studies and series supports the initial use of high-dose steroid therapy in acute lupus myocarditis.
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33
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The spectrum of myocarditis: from pathology to the clinics. Virchows Arch 2019; 475:279-301. [DOI: 10.1007/s00428-019-02615-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/15/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
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Bouiller K, Naudion P, Humbert S, Gil H, Meaux-Ruault N, Cravat M, Revel L, Molimard C, Seronde MF, Magy-Bertrand N. Cardiac Shock Revealing Systemic Lupus Erythematosus. Circ Heart Fail 2019; 11:e005159. [PMID: 29980596 DOI: 10.1161/circheartfailure.118.005159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kevin Bouiller
- Service de Médecine Interne (K.B., P.N., S.H., H.G., N.M.-B.)
| | - Pauline Naudion
- Service de Médecine Interne (K.B., P.N., S.H., H.G., N.M.-B.)
| | | | - Helder Gil
- Service de Médecine Interne (K.B., P.N., S.H., H.G., N.M.-B.)
| | | | | | | | | | - Marie-France Seronde
- and Service de Cardiologie (M.-F.S.) Centre Hospitalier Universitaire Jean Minjoz, Besancon, France
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35
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Buleu F, Sirbu E, Caraba A, Dragan S. Heart Involvement in Inflammatory Rheumatic Diseases: A Systematic Literature Review. ACTA ACUST UNITED AC 2019; 55:medicina55060249. [PMID: 31174287 PMCID: PMC6632037 DOI: 10.3390/medicina55060249] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 12/31/2022]
Abstract
Introduction: Patients with inflammatory rheumatic diseases have an increased risk of developing cardiovascular manifestations. The high risk of cardiovascular pathology in these patients is not only due to traditional cardiovascular risk factors (age, gender, family history, smoking, sedentary lifestyle, cholesterol), but also to chronic inflammation and autoimmunity. Aim: In this review, we present the mechanisms of cardiovascular comorbidities associated with inflammatory rheumatic diseases, as they have recently been reported by different authors, grouped in electrical abnormalities, valvular, myocardial and pericardial modifications and vascular involvement. Methods: We conducted a systematic search of published literature on the following online databases: EBSCO, ScienceDirect, Scopus and PubMed. Searches were limited to full-text English-language journal articles published between 2010 and 2017 using the following key words: heart, systemic inflammation, autoimmunity, rheumatic diseases and disease activity. After the primary analysis we included 50 scientific articles in this review. Results: The results showed that cardiac manifestations of systemic inflammation can occur frequently with different prevalence in rheumatoid arthritis (RA), systemic lupus erythematosus(SLE), systemic sclerosis(SSc) and ankylosing spondylitis(AS). Rheumatologic diseases can affect the myocardium, cardiac valves, pericardium, conduction system and arterial vasculature. Conclusions: Early detection, adequate management and therapy of specific cardiac involvement are essential in rheumatic disease. Electrocardiographic and echocardiographic evaluation should be performed as routine investigations in patients with inflammatory rheumatic diseases.
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Affiliation(s)
- Florina Buleu
- Departament of Cardiology, Faculty of Medicine, University of Medicine and Pharmacy "Victor Babeș", Timișoara 300041, Romania.
| | - Elena Sirbu
- Department of Physical Therapy and Special Motricity, West University of Timișoara, Timișoara 300223, Romania.
| | - Alexandru Caraba
- Departament of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy "Victor Babeș", Timișoara 300041, Romania.
| | - Simona Dragan
- Departament of Cardiology, Faculty of Medicine, University of Medicine and Pharmacy "Victor Babeș", Timișoara 300041, Romania.
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36
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Echocardiographic Assessment of Diastolic Function in Children with Incident Systemic Lupus Erythematosus. Pediatr Cardiol 2019; 40:1017-1025. [PMID: 31041461 PMCID: PMC7093038 DOI: 10.1007/s00246-019-02107-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/20/2019] [Indexed: 12/17/2022]
Abstract
The timing and etiology of diastolic impairment in pediatric-onset systemic lupus erythematosus (SLE) are poorly understood. We compared echocardiographic metrics of left ventricular diastolic function in children at SLE diagnosis to controls and identified factors associated with diastolic indices. Echocardiograms of children aged 5-18 years within 1 year of SLE diagnosis and age-/sex-matched controls were retrospectively read by blinded cardiologists. Clinical characteristics were abstracted separately. Z-scores for diastolic indices (E/A, e', E/e', and isovolumetric relaxation time (IVRT)) were calculated using published normative data and study controls, and compared using linear mixed-effects models adjusted for blood pressure. Pericardial effusions and valvular disease were also evaluated. Linear regression was used to identify factors associated with diastolic measures. 85 children with incident SLE had echocardiograms performed a median of 6 days after diagnosis (interquartile range (IQR) 1-70). Prior cumulative prednisone exposure was minimal (median 60 mg, IQR 0-1652). SLE cases had lower E/A, lower e', higher E/e', and longer IVRT compared to controls. Though none met criteria for Grade I diastolic dysfunction, Z-scores for e', E/e', and IVRT were abnormal in 30%, 25%, and 6% of SLE cases, respectively. Greater disease activity was associated with lower septal e' (p < 0.01), higher E/e' (p = 0.02), and longer IVRT (p < 0.01). Children with incident SLE have worse diastolic indices at diagnosis compared to peers without SLE, independent of blood pressure and prior to significant prednisone exposure. Longitudinal studies will determine whether diastolic dysfunction develops in this population over time.
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Nikdoust F, Bolouri E, Tabatabaei SA, Goudarzvand M, Faezi ST. Early diagnosis of cardiac involvement in systemic lupus erythematosus via global longitudinal strain (GLS) by speckle tracking echocardiography. J Cardiovasc Thorac Res 2018; 10:231-235. [PMID: 30680083 PMCID: PMC6335988 DOI: 10.15171/jcvtr.2018.40] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction: Systemic lupus erythematosus (SLE) myocarditis occurs in between 5% and 10%
of patients with lupus. Global longitudinal strain (GLS) via speckle tracking echocardiography
can detect cardiac involvement in patients suffering from SLE. We decided to determine the
echocardiographic features and subsequent early diagnosis of cardiac involvement in patients
with SLE utilizing the GLS index via speckle tracking echocardiography.
Methods: In this cross-sectional study, we compared female patients with SLE of at least 2 years’
duration and healthy controls in terms of the left ventricular (LV) GLS via speckle tracking
echocardiography. After data collection in both groups, the GLS index and the ejection fraction
were evaluated.
Results: We analyzed and compared the LV echocardiographic parameters of 33 patients with
SLE (mean age=25.45±0.63 years) with those of 35 healthy controls (mean age=27±0.45 years).
The apical 2-chamber view indicated a significant decrease in the LV GLS in the case group by
comparison with the healthy controls (P=0.005). The LV GLS in the apical 3-chamber view was
significantly lower in the case group than in the control group (P=0.006). The LV GLS in the
apical 4-chamber view revealed no significant difference between the case and healthy control
groups (P=0.2). While there was a significant difference between the case and control groups visà-
vis the LV GLS (P=0.02), the LV ejection fraction measured with the Simpson method showed
no significant difference between the 2 groups (P=0.96).
Conclusion: GLS speckle tracking echocardiography is a noninvasive method with diagnostic and
prognostic values; it may, therefore, be a sensitive marker for the diagnosis of myocarditis and
other cardiac involvements in patients with SLE.
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Affiliation(s)
- Farahnaz Nikdoust
- Department of Cardiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Bolouri
- Department of Cardiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mahdi Goudarzvand
- Department of Physiology and Pharmacology, School of medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Seyedeh Tahereh Faezi
- Department of Rheumatology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Chang JC, Xiao R, Mercer-Rosa L, Knight AM, Weiss PF. Child-onset systemic lupus erythematosus is associated with a higher incidence of myopericardial manifestations compared to adult-onset disease. Lupus 2018; 27:2146-2154. [PMID: 30318995 DOI: 10.1177/0961203318804889] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES There are no population-based estimates of the incidence or risk factors for acute cardiac manifestations in children with systemic lupus erythematosus (SLE) to guide screening and diagnostic imaging practices. We estimated the incidence and prevalence of acute cardiac manifestations of child-onset SLE compared to adult-onset SLE and identified factors associated with cardiac diagnoses. METHODS We identified children (5-17 years) and adults (18-64 years) with incident SLE (≥3 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) code 710.0, > 30 days apart) using Clinformatics® DataMart (OptumInsight, Eden Prairie, MN) deidentified United States administrative claims (2000-2013). We calculated incidence and prevalence of three outcomes: ≥ 1 diagnosis code for (1) pericarditis and/or myocarditis, (2) endocarditis, or (3) valvular insufficiency. Negative binomial regression was used to identify characteristics associated with cardiac diagnoses in children and determine whether SLE onset in childhood vs adulthood was independently associated with cardiac involvement. RESULTS There were 297 children and 6927 adults with new-onset SLE. A total of 17.8% of children had ICD-9 CM codes for acute cardiac diagnoses, the incidence of which were highest in the first year after SLE diagnosis (12.2 per 100 person-years). African American race (incidence rate ratio (IRR) 6.6, 95% confidence interval (CI) (2.9, 15.0), p < 0.01) and nephritis (IRR 7.0, 95% CI (2.6, 18.6), p < 0.01) were associated with acute cardiac diagnoses in children. Child-onset disease was independently associated with a 4.4-fold higher rate of pericarditis or myocarditis compared to adult-onset SLE after adjustment for other disease and demographic characteristics (95% CI (2.4, 8.0), p < 0.01). CONCLUSION This study establishes baseline estimates of the incidence and prevalence of pericarditis and myocarditis in child-onset SLE, which is substantially higher than that of adult-onset SLE. Prospective echocardiographic evaluations are needed to validate incidence measures and characterize the natural history of acute cardiac manifestations in child-onset SLE, as well as identify risk factors for poor cardiac outcomes to inform screening and management.
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Affiliation(s)
- J C Chang
- 1 Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,2 Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - R Xiao
- 1 Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - L Mercer-Rosa
- 3 Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,5 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - A M Knight
- 2 Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,4 Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,5 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - P F Weiss
- 2 Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,4 Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,6 Center for Pharmacoepidemiology Research and Training at the University of Pennsylvania, Philadelphia, PA, USA
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39
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The heart in systemic lupus erythematosus - A comprehensive approach by cardiovascular magnetic resonance tomography. PLoS One 2018; 13:e0202105. [PMID: 30273933 PMCID: PMC6167090 DOI: 10.1371/journal.pone.0202105] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/28/2018] [Indexed: 11/21/2022] Open
Abstract
Background In systemic lupus erythematosus (SLE), cardiac manifestations, e.g. coronary artery disease (CAD) and myocarditis are leading causes of morbidity and mortality. The prevalence of subclinical heart disease in SLE is unknown. We studied whether a comprehensive cardiovascular magnetic resonance (CMR) protocol may be useful for early diagnosis of heart disease in SLE patients without known CAD. Methods In this prospective, observational, cross-sectional study CMR including cine, late gadolinium enhancement (LGE) and stress perfusion sequences, ECG, and blood sampling were performed in 30 consecutive SLE patients without known CAD. All patients fulfilled at least 4/11 American College of Rheumatology (ACR) Criteria for the classification of SLE. Results 30 patients (83% female) were enrolled, mean age was 45±14 years and mean SLE disease duration was 10±8 years. 80% had low to moderate disease activity. All had a low SLE damage index. CMR was abnormal in 13/30 (43%), showing LGE in 9/13, stress perfusion deficits in 5/13 and pericardial effusion (PE) in 7/13. Patients with non-ischemic LGE had more often microalbuminuria while patients with stress perfusion deficits a history of hypertension, renal disorder as ACR criterion, repolarisation abnormalities on ECG and larger LV enddiastolic volume index. There was no correlation between clinical symptoms and CMR results. Conclusion Our study shows that cardiac involvement as observed by CMR is frequent in SLE and not necessarily associated with typical symptoms. CMR may thus help to detect subclinical cardiac involvement, which could lead to earlier treatment. Additionally we identify possible risk factors associated with cardiac involvement.
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Perel-Winkler A, Bokhari S, Perez-Recio T, Zartoshti A, Askanase A, Geraldino-Pardilla L. Myocarditis in systemic lupus erythematosus diagnosed by 18F-fluorodeoxyglucose positron emission tomography. Lupus Sci Med 2018; 5:e000265. [PMID: 30094040 PMCID: PMC6069920 DOI: 10.1136/lupus-2018-000265] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/24/2018] [Accepted: 06/12/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cardiovascular diseaseand heart failure (CHF) are leading causes of death in systemic lupus erythematosus (SLE). The underlying mechanisms for increased CHF in SLE are unclear but myocardial inflammation and lupus myocarditis (LM) may play a role. We propose that 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET)/CT can help diagnose LM. METHODS This report describes eight patients with presumed LM; five patients were evaluated due to active cardiorespiratory symptoms and three patients were participating in a pilot study to determine the prevalence of subclinical myocarditis in SLE. Clinical characteristics, laboratory and cardiac testing including electrocardiography (ECG), transthoracic echocardiogram (TTE), coronary artery evaluation as well as 18F-FDG-PET/CT imaging are discussed. RESULTS Four patients were African American and the others were Hispanic. Half presented with chest pain; 37% had dyspnoea and 25% were asymptomatic. The median SLE Disease Activity Index (SLEDAI-2K) was 5 (2-18) and SLICC Damage Index (SDI) 0.5 (0-5). The median troponin level was 0.08 ng/mL (0-0.9). The most common ECG findings were non-specific ST-T wave abnormalities (n=5). Fifty per cent of the patients had a decreased ejection fraction on TTE and all patients had diffuse myocardial FDG uptake on 18F-FDG-PET/CT consistent with myocardial inflammation. CONCLUSION This case series is the first to describe the use of 18F-FDG-PET/CT in the diagnosis of LM and discuss the clinical characteristics and cardiac findings of eight patients with LM supporting the role for cardiac 18F-FDG-PET/CT in its diagnosis.
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Affiliation(s)
- Alexandra Perel-Winkler
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Sabahat Bokhari
- Division of Cardiology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
- Nuclear Cardiology Laboratory, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Thania Perez-Recio
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Afshin Zartoshti
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Anca Askanase
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Laura Geraldino-Pardilla
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
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Tanwani J, Tselios K, Gladman DD, Su J, Urowitz MB. Lupus myocarditis: a single center experience and a comparative analysis of observational cohort studies. Lupus 2018; 27:1296-1302. [PMID: 29642752 DOI: 10.1177/0961203318770018] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Lupus myocarditis (LM) is reported in 3-9% of patients with systemic lupus erythematosus (SLE) but limited evidence exists regarding optimal treatment and prognosis. This study aims to describe LM in a defined lupus cohort as compared with the existing literature. Patients and methods Patients with LM were identified from the University of Toronto Lupus Clinic database. Diagnosis was based on clinical manifestations and electrocardiographic, imaging, and biochemical criteria. Demographic, clinical, diagnostic and therapeutic variables and outcomes were collected in a standardized data retrieval form. A literature review was performed to identify cohort studies reporting on LM treatment and outcome. A comparative analysis was conducted between our patients and the combined cohort of the existing studies. Results Thirty patients were diagnosed with LM (prevalence 1.6%) and compared with a cumulative cohort of 117 patients from five distinct studies. No significant differences were found regarding the age at diagnosis (32.6 ± 13.4 years) and SLE duration (2.5 years median). Concomitant lupus activity from other organ systems was observed in 97% of the patients. Chest pain was more frequently reported in our cohort whereas dyspnea was more prominent in the other studies. Diagnostic criteria were similar across studies. Therapeutic approach was comparable and consisted of glucocorticosteroids (96.6%) and immunosuppressives (70%). Mortality was approximately 20% whereas another 20% of the patients achieved partial and 60% complete recovery. Conclusions LM usually occurs early in the disease course and in the context of generalized lupus activity. Despite aggressive therapy, approximately 40% of the patients died or had residual heart damage.
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Affiliation(s)
- J Tanwani
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - K Tselios
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - D D Gladman
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - J Su
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - M B Urowitz
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
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Tariq S, Garg A, Gass A, Aronow WS. Myocarditis due to systemic lupus erythematosus associated with cardiogenic shock. Arch Med Sci 2018; 14:460-462. [PMID: 29593821 PMCID: PMC5868675 DOI: 10.5114/aoms.2017.68692] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/04/2015] [Indexed: 12/18/2022] Open
Affiliation(s)
- Sohaib Tariq
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Anjali Garg
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Alan Gass
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Wilbert S Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
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Hasham MG, Baxan N, Stuckey DJ, Branca J, Perkins B, Dent O, Duffy T, Hameed TS, Stella SE, Bellahcene M, Schneider MD, Harding SE, Rosenthal N, Sattler S. Systemic autoimmunity induced by the TLR7/8 agonist Resiquimod causes myocarditis and dilated cardiomyopathy in a new mouse model of autoimmune heart disease. Dis Model Mech 2017; 10:259-270. [PMID: 28250051 PMCID: PMC5374321 DOI: 10.1242/dmm.027409] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 01/18/2017] [Indexed: 12/21/2022] Open
Abstract
Systemic autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) show significant heart involvement and cardiovascular morbidity, which can be due to systemically increased levels of inflammation or direct autoreactivity targeting cardiac tissue. Despite high clinical relevance, cardiac damage secondary to systemic autoimmunity lacks inducible rodent models. Here, we characterise immune-mediated cardiac tissue damage in a new model of SLE induced by topical application of the Toll-like receptor 7/8 (TLR7/8) agonist Resiquimod. We observe a cardiac phenotype reminiscent of autoimmune-mediated dilated cardiomyopathy, and identify auto-antibodies as major contributors to cardiac tissue damage. Resiquimod-induced heart disease is a highly relevant mouse model for mechanistic and therapeutic studies aiming to protect the heart during autoimmunity. Summary: A novel mouse model of autoimmune-mediated heart damage to study the underlying mechanisms and test therapeutic options for systemic autoimmunity.
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Affiliation(s)
- Muneer G Hasham
- The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA
| | - Nicoleta Baxan
- Biological Imaging Centre, Department of Medicine, Imperial College London, London W12 0NN, UK
| | - Daniel J Stuckey
- Centre for Advanced Biomedical Imaging, Division of Medicine, University College London, London WC1E 6DD, UK
| | - Jane Branca
- The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA
| | - Bryant Perkins
- The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA
| | - Oliver Dent
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Ted Duffy
- The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA
| | - Tolani S Hameed
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Sarah E Stella
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Mohammed Bellahcene
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Michael D Schneider
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Sian E Harding
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Nadia Rosenthal
- The Jackson Laboratory, 600 Main Street, Bar Harbor, ME 04609, USA.,National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
| | - Susanne Sattler
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK
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Shintaku M, Uchiyama K, Kobayashi Y. Chronic myocarditis with a long clinical course: Report of an autopsy case of probable autoimmune myocarditis. Pathol Int 2017; 67:521-525. [DOI: 10.1111/pin.12568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Masayuki Shintaku
- Department of Pathology; Shiga Medical Center for Adults; Moriyama Shiga Japan
| | | | - Yohei Kobayashi
- Department of Cardiology; Osaka Red Cross Hospital; Osaka Japan
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Cooray S, Zhang H, Breen R, Carr-White G, Howard R, Cuadrado M, D’Cruz D, Sanna G. Cerebral tuberculosis in a patient with systemic lupus erythematosus following cyclophosphamide treatment: a case report. Lupus 2017; 27:670-675. [DOI: 10.1177/0961203317722849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S Cooray
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
- Department of Respiratory Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - H Zhang
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - R Breen
- Department of Respiratory Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - G Carr-White
- Cardiothoracic Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - R Howard
- Department of Neurology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - M Cuadrado
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - D D’Cruz
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - G Sanna
- Louise Coote Lupus Unit, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
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Du Toit R, Herbst PG, van Rensburg A, Snyman HW, Reuter H, Doubell AF. Speckle tracking echocardiography in acute lupus myocarditis: comparison to conventional echocardiography. Echo Res Pract 2017; 4:9-19. [PMID: 28490455 PMCID: PMC5510444 DOI: 10.1530/erp-17-0005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 12/31/2022] Open
Abstract
Aims Lupus myocarditis occurs in 5–10% of patients with systemic lupus erythematosus (SLE). No single feature is diagnostic of lupus myocarditis. Speckle tracking echocardiography (STE) can detect subclinical left ventricular dysfunction in SLE patients, with limited research on its utility in clinical lupus myocarditis. We report on STE in comparison to conventional echocardiography in patients with clinical lupus myocarditis. Methods and results A retrospective study was done at a tertiary referral hospital in South Africa. SLE patients with lupus myocarditis were included and compared to healthy controls. Echocardiographic images were reanalyzed, including global longitudinal strain through STE. A poor echocardiographic outcome was defined as final left ventricular ejection fraction (LVEF) <40%. 28 SLE patients fulfilled the criteria. Global longitudinal strain correlated with global (LVEF: r = −0.808; P = 0.001) and regional (wall motion score: r = 0.715; P < 0.001) function. In patients presenting with a LVEF ≥50%, global longitudinal strain (P = 0.023), wall motion score (P = 0.005) and diastolic function (P = 0.004) were significantly impaired vs controls. Following treatment, LVEF (35–47% (P = 0.023)) and wall motion score (1.88–1.5 (P = 0.017)) improved but not global longitudinal strain. Initial LVEF (34%; P = 0.046) and global longitudinal strain (−9.5%; P = 0.095) were lower in patients with a final LVEF <40%. Conclusions This is the first known report on STE in a series of patients with clinical lupus myocarditis. Global longitudinal strain correlated with regional and global left ventricular function. Global longitudinal strain, wall motion score and diastolic parameters may be more sensitive markers of lupus myocarditis in patients presenting with a preserved LVEF ≥50%. A poor initial LVEF and global longitudinal strain were associated with a persistent LVEF <40%. Echocardiography is a non-invasive tool with diagnostic and prognostic value in lupus myocarditis.
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Affiliation(s)
- Riëtte Du Toit
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Phillip G Herbst
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Annari van Rensburg
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Hendrik W Snyman
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Helmuth Reuter
- Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Anton F Doubell
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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Le Borgne P, Brunhuber C, Kam C, Lavoignet C, Bilbault P. Une cause rare d’insuffisance respiratoire aiguë. Rev Mal Respir 2017; 34:268-270. [DOI: 10.1016/j.rmr.2016.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 09/17/2016] [Indexed: 11/27/2022]
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48
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Mavrogeni S, Koutsogeorgopoulou L, Dimitroulas T, Markousis-Mavrogenis G, Kolovou G. Complementary role of cardiovascular imaging and laboratory indices in early detection of cardiovascular disease in systemic lupus erythematosus. Lupus 2017; 26:227-236. [DOI: 10.1177/0961203316671810] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background Cardiovascular disease (CVD) has been documented in >50% of systemic lupus erythematosus (SLE) patients, due to a complex interplay between traditional risk factors and SLE-related factors. Various processes, such as coronary artery disease, myocarditis, dilated cardiomyopathy, vasculitis, valvular heart disease, pulmonary hypertension and heart failure, account for CVD complications in SLE. Methods Electrocardiogram (ECG), echocardiography (echo), nuclear techniques, cardiac computed tomography (CT), cardiovascular magnetic resonance (CMR) and cardiac catheterization (CCa) can detect CVD in SLE at an early stage. ECG and echo are the cornerstones of CVD evaluation in SLE. The routine use of cardiac CT and nuclear techniques is limited by radiation exposure and use of iodinated contrast agents. Additionally, nuclear techniques are also limited by low spatial resolution that does not allow detection of sub-endocardial and sub-epicardial lesions. CCa gives definitive information about coronary artery anatomy and pulmonary artery pressure and offers the possibility of interventional therapy. However, it carries the risk of invasive instrumentation. Recently, CMR was proved of great value in the evaluation of cardiac function and the detection of myocardial inflammation, stress-rest perfusion defects and fibrosis. Results An algorithm for CVD evaluation in SLE includes clinical, laboratory, ECG and echo assessment as well as CMR evaluation in patients with inconclusive findings, persistent cardiac symptoms despite normal standard evaluation, new onset of life-threatening arrhythmia/heart failure and/or as a tool to select SLE patients for CCa. Conclusions A non-invasive approach including clinical, laboratory and imaging evaluation is key for early CVD detection in SLE.
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Affiliation(s)
- S Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece
| | - L Koutsogeorgopoulou
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | - T Dimitroulas
- 4th Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - G Kolovou
- Onassis Cardiac Surgery Center, Athens, Greece
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Abstract
Systemic lupus erythematosus is an autoimmune disease with diffuse organ involvement. The cardiac complications include pericarditis, myocarditis, pulmonary hypertension, coronary vasculitis, and Libman-Sacks endocarditis. Symptomatic lupus myocarditis presenting with left ventricular dysfunction, acute heart failure, and pulmonary edema, although rare, is a life-threatening complication. We report the occurrence of acute lupus myocarditis in a 38-year-old postpartum female who had a cesarean section a week before presentation for preeclampsia. Initially she was managed for pneumonia but later found to have acute pericarditis and myocarditis related to systemic lupus erythematosus. She had a complicated hospital course including acute respiratory failure and cardiogenic shock. She was started on pulse dose steroids besides the treatment for heart failure and had a dramatic improvement within days.
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Generali E, Folci M, Selmi C, Riboldi P. Immune-Mediated Heart Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1003:145-171. [PMID: 28667558 DOI: 10.1007/978-3-319-57613-8_8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The heart involvement in systemic autoimmune diseases represents a growing burden for patients and health systems. Cardiac function can be impaired as a consequence of systemic conditions and manifests with threatening clinical pictures or chronic myocardial damage. Direct injuries are mediated by the presence of inflammatory infiltrate which, even though unusual, is one of the most danger manifestations requiring prompt recognition and treatment. On the other hand, a not well-managed inflammatory status leads to accelerated atherosclerosis that precipitates ischemic disease. All cardiac structures may be damaged with different grades of intensity; moreover, lesions can appear simultaneously or more frequently at a short distance from each other leading to the onset of varied clinical pictures. The pathogenesis of heart damages in systemic autoimmune conditions is not yet completely understood for the great part of situations, even if several mechanisms have been investigated. The principal biochemical circuits refer to the damaging role of autoantibodies on cardiac tissues and the precipitation of immune complexes on endocardium. These events are finally responsible of inflammatory infiltration which leads to subsequent worsening of the previous damage. For these reasons, it appears of paramount importance a regular and deepened cardiovascular assessment to prevent a progressive evolution toward heart failure in patient affected by autoimmune diseases.
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Affiliation(s)
- Elena Generali
- Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Folci
- Allergy, Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Carlo Selmi
- Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy.,BIOMETRA Department, University of Milan, Milan, Italy
| | - Piersandro Riboldi
- Allergy, Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy.
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